Does Diabetes Hurt?

In 2008, I wrote a five-partseries onchronic pain and diabetes. Pain hasn’t gone anywhere, and people still aren’t talking about it much. But new research is helping us understand pain better and treat it more effectively.

First the bad news — the amount of pain people with diabetes have is staggering. A study of over 13,000 adults with Type 2 diabetes by researchers in California found that nearly half report significant pain.

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A University of California, San Francisco, press release stated, “Patients in the study reported significant pain and nonpain symptoms [such as insomnia and depression] across the entire course of the disease, among all age groups, with prevalence increasing as people neared the end of their lives.”

Lead author Rebecca Sudore, MD, said, “Adults living with Type 2 diabetes are suffering from incredibly high rates of pain, at levels similar to patients living with cancer.”

That phrase “similar to patients living with cancer” really threw me. I mean, cancer is awful, and often brings terrible pain, but people with cancer don’t have to do much besides fight to live and hope their treatments work. They can focus a lot of energy on reducing pain, and their doctors are likely to at least try to help.

But for people with diabetes, no matter how much pain they’re in, they still have to focus on controlling their blood glucose levels. Rather than figuring out, “how can I get comfortable?” they may have to make themselves less comfortable with fingersticks. They have to exercise and worry about what they eat. Their doctors don’t prioritize their pain or know what to do about it, if people even bother to tell them.

Chronic pain has been found to interfere with diabetes self-management in several ways. A 2005 study in the journal Diabetes Care reported, “Patients with chronic pain had poorer diabetes self-management overall and more difficulty following a recommended exercise plan and eating plan.” They also had a harder time taking medications correctly, probably because they were on so many medicines.

So what is causing all this pain? The most obvious answer is “peripheral neuropathy” (PN), damage to small nerves in the feet, hands, arms, and legs caused by high blood glucose levels. Pain expert Dr. Scott Fishman said, “Diabetes starves these tiny nerves. As a result, the nervous system becomes confused about what is and isn’t painful. Stockings, gloves — anything that that touches skin served by these tiny, hypersensitive nerves is going to send signals to the spinal cord, where they may be mistaken for pain.”

So diabetes directly causes PN pain. But a British study from 2006 found that, while over 26% of people with diabetes reported painful PN, 36.8% of subjects with diabetes reported other, nonneuropathic pain. Major categories of reported pain included back pain, headaches, and abdominal pain, but it seems people with diabetes have more pain in general. They also have more depression, which is often considered a form of “psychological pain.” Why should this be?

Studies show that the risk factors for chronic pain are similar (or the same) as those for diabetes. These include low social or economic status, membership in a discriminated–against group, a history of trauma, physical inactivity, relatively low self-confidence or self-esteem, and a lack of social support.

These mostly nonphysical factors play a big role in chronic pain, because pain is our bodies’ way of telling us when something is wrong. The body doesn’t have a whole lot of ways to communicate. Pain, fatigue, nausea, and maybe a couple of other symptoms are its only ways of getting our attention.

Pain may start with some signals sent by peripheral nerves. But these signals get mixed with emotions, and either amplified or turned down by anxiety, anger, grief, and stress. So the harder life, the more pain you are likely to feel.

Conversely, people who have relatively easy lives — with lots of money, love, meaning, pleasure — may not feel much pain in spite of having cancer, arthritis, or diabetes. Their nervous systems are turned down to a comfortably low level, not amped up to a level that makes everything hurt.

Fortunately, the many causes of pain in diabetes mean there are many ways to treat it. A variety of different classes of medications can help — not just narcotics, but medicines for seizures, depression, anxiety, and inflammation. I’m going to have to address those later, because I’m running out of space here.

For this week, I want to cite a nondrug approach to PN involving electricity. You may have heard of TENS (transcutaneous electrical nerve stimulation) systems. These are normally electrodes placed on the painful area. Gentle current is passed through them into the nerves, where they block pain signals. These units work well for many people.

A company called Neurometrix has come out with a system called the Sensus Pain Management Sytem, a box about the size of a glucose meter that you strap to your upper calves and use to control pain. When pain bothers you, you just push a button and the signals are largely blocked. It’s very new, but might be worth looking into.

There are many other things you can do about pain, but I would first like to know your pain experience. How big a role does pain play in your life? Does it interfere with other things? What have you been able to do about it?

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Rita Velez

I have been a Type 2 diabetic since 2003. My pain actually started before I was diagnosed with my 2nd toe going completely numb. The numbness has progressed till now with numbness and pain in both legs (from the knees down)& feet. The pain is worse at night, making it hard to sleep, I have tried many OTC remedies, but none has done as well as Aleve. I actually have relief for almost 24 hours with 1 dose of 2 pills, and can go shopping or walking for a few hours. I don’t think doctors understand that to keep diabetes in check, you have to move, but when you have pain it is very difficult. Thus numbers don’t go down where they should be. I will continue to find OTC meds to use if Aleve ever stops working for me, because I don’t ever want to get into narcotics. I do worry how all these medications are going to affect me in the future, but for now, I take what I need to keep moving.

Michael Baynard

I have been diagnosed with type 2 diabetes since Jan of 2007. SInce then, I have gone through a number of medications, having recently (in last 3 months) added pen dispensed insulin shots once daily. This has brought my sugar down to a much more tolerable rate, but the pain in my feet has slowly increased over the last 12 – 15 months. I have some neuropathy starting and I have the “pins and needles” effect with my feet and weakness in my left shoulder due to unknown reasons. I work at my desk with my shoes off most times to control the feeling, but constantly move my feet around to try to make them feel even better. I take Gabapentin (spelled?) for the circulatory help, which helped in the beginning, but not as much any more. I am hoping to start getting my weight down now that my sugar is better regulated. Not sure if my feet will ever be the same again, but if I can reverse the Type 2, it will all be worth it. Mike in Yorktown

Americo Mezovari

type 2 since 2000 on and off oral meds,never had pain in legs or anywhere else for that matter my work is labor intensive didn`t exercise till now
every day twice a day take my oral meds 3 times aday and insulin once before bed i also eat right
because i don`t want to lose my other foot
below the knee amputation
Good Luck

Gary Ferrini

I have had type II diabetes since 1986, but vis a vis the wonders of modern medicine, went undiagnosed until 2003, so the disease was well downstream when I finally got diagnosed. Since then, I’ve been treated with a maelstrom of meds and in that time, besides gaining nearly 100 lbs, from side effects and inactivity (5 knee surgeries during the undiagnosed period led to total mutilation of my joints) I’ve become a pain patient and little more. Prior to diagnosis and treatment, I was a very very avid skier, mountain biker and daily high altitude hiker. I had no idea I was only adding to what would become chronic pain and only the first signs of peripheral neuropathy, plus having been a serious athlete all along “played through the pain” right up until I no longer could walk, to say nothing of rigorous activity.
So when I read the question about pain and diabetes, I had to laugh. I now live a life where the big questions include, “Can I put on my socks or should I wait?,” “I wonder if taking the garbage out is too much,” and “I don’t know about a shower. Maybe tomorrow.” Pain rules my life and that’s with strong pain meds as palliative. Beyond a point, they’re moot.
I find the treatment well intended but mostly primitive as the choices seem to be between dying from the ravages of diabetes or those of obesity. I used to wonder why certain diabetics looked just like the Michelin Man and now I wonder if I can find a wardrobe from the Pavarotti collection or just live in sweatpants and loose teeshirts. Togas to follow. The dietary counseling I’ve gotten seems to have been developed at some point during the Crusades and no matter how often I tell doctors and dieticians that the pyramid diet, even in small and frequent portions is a prescription for disaster, they stare me down as if I hadn’t read the latest detritus from the studies. There are times I wish every one of them had diabetes, peripheral neuropathy and pain the likes of which would bring them to tears so I could then ask if they think their former arrogance was warranted. But who am I kidding? The irony is that the overwhelming preponderance of employees in most any medical office look morbidly unhealthy and generally speaking, very overweight. Just not with diabetes (YET)
I’ve tried TENS units a lot. Fine while they’re at work but with no carryover at all and one can’t very well spend a life walking around with them all day. They are not totally ineffective but they at best, manage, not remedy pain.
I have never heard of the SENSUS pain management system until today. I’ll look into it but with some skepticism because frankly, most everything I’ve ever tried has relieved only my wallet and not my pain.
I’d also like to say that the very treatment of pain in this society is insane. Is it a sin to be tolerated like a hair shirt or some time on a bed of nails? And why do doctors spend more time concerned with abuse of meds than the patients in severe pain? I understand there is a problem with pain medication, addciction and so on, but how does one weigh that against the pain itself and those whose lives have been completely ruined? Is one addicted to blood pressure medication he or she must take for life? And if I walk into an office and request viagra why is that no problem but to have my pain treated is tantamount to being a criminal? I’d be my life that any pain patient reading this understands exactly what I mean but medical professionals, not so much. The distance and indifference can be stunning.
Long ago, in another life I was the head of marketing for a medical company. I met and talked to untold numbers of physicians, having no idea I’d one day be at their mercy. What struck me then and is only worse now, is how much the profession was informed and driven by two things: Money and fear of lawyers. Patients are media for the income but rarely the priority. Just think of how things go when you enter a doctor’s office and how much time you get with the doctor compared to his/her staff and filling out forms. Diabetics are just spoke on that wheel and a spoke which demands a lot of treatment, meds and provides more incentive for treatment than cure. Pain just an artifact of the bigger picture.
I’m glad you’re interested in these matters but without a dramatic overhaul of the way we train physicians and regulate treatment, it’s mostly not something most patients can begin to fix and especially when their illnesses rob them of vitality and even hope.

shirley fontanelli

I have neuropathy in my feet from Type 2 diabetis. My poditrist recommended I try a new product called NeuRemedy. It is a new neiropathy vitamin. He sold it to me from his office and I have seen amazing results. I still have some neuropathy, but not as severe. I truly recommenc it to you.

Judy Swift

I have had diabetes for a number of years. Currently I take meds and insulin. I have had alot of pain in my legs and feet. I, also have no feeling from below my knees to the tip of my toes. I get pain impulses. I will have a really sharp, stabbing pain which will come and let up inhyer a matter of seconds followed with another pain. I do get pretty tired of having to test my blood sugar and take the insulin. I just can not seem to get a grip on the sugars. I admit that I also find it hard to stay away from sweets which I know just adds to everything.

Lynne Nelson

I have had Type 2 since 2001. I have been able to control my blood glucose by eating a low carb diet and exercise, so I take no medication at present. However, I read early on that Alpha Lipoic Acid may prevent and possibly reverse diabetic neuropathy. I have been taking this supplement for at least ten years. I also read that the most widely prescribed diabetic drug, metformin may cause a decrease in vitamin B-12, which eventually may lead to the peripheral neuropathy that many diabetics experience. I’ve found that there are choices for diabetics, but no easy answers. My uncle lost both of his limbs to diabetes and my grandmother became blind. So, I resolved not to be passive when I was told that I had diabetes also.

Tim ONeil

I was diagnosed in 1996, and stayed controlled, with A1C usually ranging 5.9-6.1. Spent a tour in 2008-2009 as a contractor in Iraq, and was able to control blood sugars even in that environment through basal insulin (even though I wasn’t supposed to deploy on insulin).
I have also had chronic pain since a motorcycle accident in 1986 ending with compression fractures at T3,T5, and T7. It seems like I have always had pain from the nipple line down to the base of the chest since that accident. But I have also dealt with it, especially my time with the military which taught me to ignore the pain, and complete the mission.
But now it has progressed dramatically. I had what I thought was a heart attack (twice), and it turned out to be a focal neuropathy. If you have never experienced the pain associated with a focal neuropathy, then you are inexperienced when it comes to pain. I had to change my pain scale after experiencing one of these attacks. Waterboarding and electric shock would be considered mild in comparison to this experience.
I have also developed a case of autonomic neuropathy. It was noticed that I had an elevated heart rate after the first focal attack in 2009. I had returned from Iraq a couple of months earlier, and was running about 4 miles a day. I maxed out the treadmill, and was running uphill at a rapid pace to get my heart rate to target of 178, and the exercise portion of the test lasted 20 minutes to hit the target. (However, my base rate was 110, and for the majority of the exercise period, it did not go above 140.) This contrasts with a stress test done in 2011 where my exercise tolerance was so low, I hit target in 4 minutes of a mild walk, and felt exhausted afterward. This was also the hardest thing to find out, since it is only ruled out through exclusion of other things that could be the cause.
I also believe that the hardest part is that people don’t understand how much pain you are dealing with at one time. I have laid in bed trying to go to sleep, and mentally examining my body, searching for a spot that didn’t ache. That ‘s when life really sucks.

Charlene Dolos

I was diagnosed with Type II in 2003, prior to that the doctor warned me I had pre-diabetes. I have been on Metformin ever since. I take 1 tablet after each meal. My latest lab test showed my A1C of 6.1. Weight is not a problem, I weigh 126.7 pounds. The only pain I have is in my thighs. My doctor sent me to the University Hospital lab for Neuropathy and DVT tests. The results showed that I have neuropathy in my thighs only – NO hand or feet problems. It usually appears as I am lying down ready to sleep. My legs felt like they are on fire. My doctor prescribed 600 mg Gabapentin and 10 mg Cyclobenzaprine, three times a day. I also take Nabumetone (Relafen)for my back.
I find it difficult to exercise due to my back problems. I have had 5 back surgeries. I was also diagnosed with Periformis Syndrome in my left buttocks, which is painful when I walk, stand or sit too long. I occasionally use a pedometer to count steps & miles. The last reading showed 1.87 miles, after I went shopping. I am always in pain.

Scott K. Johnson

Thanks for the articles, David, very informative and appreciated. Also lots of great discussion here.

Stacy Hurt

Has anyone had success with topical pain creams for diabetic neuropathy?

Ana Ferrer

I became diabetic after I had my 3rd child in 1975 I suffer pain in my legs so bad that I get anxiety . I get a lot.of movements and spasms.I get a little relive with cold water and drinking pro pel

Dave Hubbs

In response to Gary Ferrini’s comments on Feb 6, 2013. You pain and frustration shouldn’t give me comfort but it does but only because the words you wrote could have come from my own mouth. I have suffered from Type II for over 16 years now and in the last year have add to triple my insulin therapy to try and manage my diabetes and have gained over 75 pounds since. The typical response I get from doctors and dieticians are “you need to eat less and move move” Very easy to say for some one not suffering from Diabetic Neuropathy so severe it has brought me to tears and made me wish I was 6 feet under. I find it interesting too that they forget that insulin is has weight gaining properties that add to the task of getting in shape. I like Gary was a competitive athlete most of my life, hockey, basketball and golf mainly. Now my exercise consists of trying to tie my shoes and balancing in the shower since I can no longer feel either foot from the mid section to the toes. When I explain all these problems to my endocrinologist and my family doctor I get the usually response, you need to keep tight control of you diabetes. For the last 6 months my A1c has been around 7 , not perfect but not too bad and still the pain continues. Recently i have started to feel the same pain in my hands and feel it is only a matter of time until i will be in so much pain it will be impossible to work to which healthy people wont be able to understand since they cant see my pain and they certainly cant see it. I wish there was a greater understanding of DPN out there….

David Spero RN

Hi Dave,

My heart goes out to you, and your story makes me angry. You should probably not be on insulin, but an A1C over 7 is too much.

I want to give you hope that this neuropathy can be greatly improved — if you can get your A1c below 6. You will probably have to make some radical changes in your diet. Please review the ideas in my article “Reversing Type 2 Diabetes: Can it be Done? Maybe one of them will appeal to you.

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